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Dermatology Educational Resource DERMATOLOGY EDUCATIONAL RESOURCE A Scaly Periorbital Rash in a Preschool-aged Boy ABSTRACT A healthy 4-year-old boy presented with an 8-month history of a pruritic scaly eruption around his right eye associated with several small pearly papules on the face. A clinical diagnosis of an eczematous id reaction to molluscum contagiosum was made. While up to 40% of cases of molluscum contagiosum may have an associated eczematous dermatitis, these are often under-recognized or misdiagnosed. KEYWORDS: Pediatrics, Dermatology, Dermatitis, Molluscum, Eczema, Id reaction, Viral exanthem, Hypersensitivity Case 1: A scaly periorbital rash in a preschool-aged boy Figure 1: Photograph of patient’s right A previously healthy 4-year-old boy presented eye (informed consent was obtained for with a pruritic scaly eruption around the right publishing these photos) eye that had been present for approximately 8 months. His parents had not noticed any other rashes or skin lesions. His past medical history was unremarkable and he was not on any medications. There was no history of atopy in the patient or other family members. Family history was only significant for molluscum contagiosum in his 3-year-old brother. Review of systems was unremarkable. On examination, the patient had a unilateral scaly eruption with mild underlying erythema on the right upper and lower eyelids (Figure 1). ABOUT THE AUTHORS Jennifer Smitten, MD, FRCPC, BC Children’s Hospital, University of British Columbia, BC. Joseph M Lam, MD, FRCPC, Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC. Eczematous Id Reaction to Gross Appearance of Molluscum Molluscum Contagiosum Contagiosum with Eczematous Id Reaction Small smooth pink or skin-coloured papules Pruritic scaly rash Histology of Molluscum Contagiosum Distinctive cup-shaped lesion composed of molluscum bodies in the epidermis above the stratum basale Molluscum bodies Stratum basale Verrucous epidermal hyperplasia with acanthosis A scaly periorbital rash in a preschool-aged boy The left eye and both conjunctivae Lesions are usually diagnosed appeared normal. On closer based on the classic appearance of inspection, additional lesions were small smooth pink or skin-coloured noted that revealed the diagnosis. papules with or without central umbilication. The infection can Case diagnosis: Eczematous id trigger a secondary inflammatory reaction to molluscum contagiosum reaction, known as an eczematous On closer inspection, this patient id reaction.1 While the diagnosis was noted to have multiple small of MC is straightforward for most flesh-coloured pearly papules pediatricians, the recognition of on the face, including one on the the eczematous id reaction may be right upper eyelid near the lateral easily missed. In a recent review canthus. These lesions confirmed of 696 pediatric patients with MC, the diagnosis of an eczematous 38.8% had an associated eczematous id reaction to molluscum dermatitis.2 This is higher than contagiosum (MC) (Figure 2). previously reported, possibly due Molluscum contagiosum is a to under-recognition. These id poxvirus that commonly affects reactions tend to be more difficult to children 2-6 years of age, with diagnose than the primary papular a second peak in young adults. lesions because the morphology can vary and they may occur Figure 3: Various sites of id reactions on the body either at the site of the molluscum papules or at a distant site (Figure 3). Appropriate recognition is important, as treatment of the pruritic id reactions can reduce spread of MC via autoinoculation from scratching. In addition, under-recognition or misdiagnosis may result in inappropriate or unnecessary treatment. Asymptomatic id reactions do not require pharmacologic treatment and a watchful waiting approach is reasonable. In cases of unilateral periorbital dermatitis, an allergic contact dermatitis is important to consider on the differential diagnosis, either as an allergen directly placed on the periorbital skin or one that has been handled 20 Journal of Current Clinical Care Volume 5, Issue 5, 2015 A scaly periorbital rash in a preschool-aged boy SUMMARY OF KEY POINTS Eczematous id reactions to molluscum contagiosum (MC) in Id reactions can be caused by a variety of infectious and children are common, occurring in up to 40% of cases of MC. noninfectious dermatoses. Id reactions to MC can be challenging to diagnose, as they Asymptomatic id reactions do not require pharmacologic may occur at sites distant from the MC lesions. treatment and a watchful waiting approach is reasonable. with fingers and later rubbed over prescribed a topical corticosteroid the eyes. for the symptomatic eczematous Id reactions can be caused reaction. In follow-up 2 weeks by a variety of infectious and later, the pruritic scaly rash that noninfectious dermatoses. had been present for several Common infectious triggers include months had completely resolved dermatophyte infections such as and the majority of the molluscum tinea capitis and tinea pedis as lesions had cleared. well as infestations such as scabies. Noninfectious causes include allergic Financial disclosure: None contact dermatitis, such as to nickel. Conflicts of interest: None Recognition and treatment of the References underlying cause is paramount. 1. Elena Netchiporouk and Bernard A. Cohen, In this case, we made the “Recognizing and managing eczematous id reactions to molluscum contagiosum virus in children,”. clinical diagnosis of MC with an Pediatrics 129,(no. 4, (2012):e1072-75. associated eczematous id reaction. 2. EM Berger et al., “Experience with molluscum contagiosum and associated inflammatory reactions in We treated the molluscum lesions a pediatric dermatology practice: the bump that rashes,”. with topical cantharidin and Archives of dermatology 148,( no. 11)(2012):1257-64. + CLINICAL PEARLS Id reactions can be caused by a variety of infectious and noninfectious dermatoses, including allergic contact dermatitis to nickel, scabies infestation, tinea infection and molluscum infection. In a unilateral eczematous dermatitis, consider molluscum dermatitis, especially in a child with no personal or family history of atopy Treatment of symptomatic id reactions may help to reduce spread of MC via autoinoculation from scratching. 21 Journal of Current Clinical Care Volume 5, Issue 5, 2015 .
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